Second-Guessing Carb Counting: Is There a Better Way?

We diligently check the carb counts on food packaging, and do the carb-counting guess-math in our heads any time we've got food in front of us on the table.

But as any PWD (person with diabetes) knows, carb counting is not a perfect science.

Just ask anyone with diabetes who's eaten pizza or a fat-heavy meal and tried to gauge how to dose insulin correctly over an extended length of time. We try and try to count the precise amounts of carbs in food, but often just can't find the magic number to keep our glucose levels in check.

So is carb-counting really the best method for a PWD to live by? Maybe not... Researchers are now exploring just how beneficial it really is, and what alternatives or "hybrid methods" might be used to best help PWDs match insulin to what is being eaten.

This topic emerged at the American Diabetes Association's Scientific Sessions this past June, with several different research teams presenting data -- including a team from Australia that's leading the charge on a possible alternative way to calculate insulin doses.

"For people with diabetes, the message is that carbohydrate counting is not the gold standard standard that we thought it was," said Professor Jennie Brand-Miller of the University of Sydney in Australia, one of the researchers studying this issue. "Perhaps it gets a bronze medal, but we are still looking for the gold standard."

A meta-analysis published in the late October edition of the new Lancet Diabetes & Endocrinology journal analyzed more than 300 studies on different methods of insulin-dosing for food in about 700 PWDs -- 599 adults and 104 kids with type 1. The two methods were carb counting and other "general or alternative dietary advice," which the researchers tell us basically involved general healthy eating tips and sometimes low glycemic food education. Brand-Miller was a lead doctor on the study, along with Kirstine Bell who's a dietician and D-educator at the University of Sydney.

Overall, there wasn't any "significant improvement" in A1C for those who counted carbs, compared to the others in this randomized study, Bell tells us. But that isn't to say carb counting lacks any merit; it just may not be the full picture and there isn't any research out there showing otherwise.

"For some people, they may find that carbohydrate counting may not give the complete picture when it comes to determining mealtime insulin doses," Bell wrote to us in an email response. "There may be other factors that are also affecting how much insulin is needed to cover meals, including fat and protein. If you are having trouble managing your blood glucose levels despite accurate carbohydrate counting, we would recommend talking to your diabetes team."

Interestingly, Bell and other researchers involved in related studies are not suggesting NOT using carb counting; rather, they say it can't stand on its own and should be combined with other methods like factoring in fat, protein, and just overall timing of how long food stays in the system. The researchers say current education lacks because so many PWDs and families are only being taught to rely on carb counting alone.

OK, but how else can we approach dosing decisions?

A New Food Insulin Index (FII)

One option that Bell and Brand-Miller say could have potential is called the Food Insulin Index (FII), an investigational algorithm that can be used to measure how much insulin is best used for a particular food. The FII includes about 130 foods ranging from bread, apples, yogurt, chicken and beef. The index uses a formula based on 100g of food, measuring the impact over the course of 120 minutes after eating.

Brand-Miller says the index isn't any more complicated than carb counting --it's just another set of numbers to learn. If PWDs can be taught that a slice of bread is 15g of carb, then they can be taught that a similar slice of bread is worth 20 points on the index.

Bell agrees.

"The FII is a more logical way of estimating insulin doses, but it's still in the early stages of development. If further studies are successful, then its practical use would be as simple as carbohydrate counting at present," she said. "If we can develop satellite navigation and Google maps, we can develop an FII."

The Australian researchers say they're now conducting a 12-week pilot study comparing FII use with carb counting, and that more foods are being tested and added to the database. They're also creating an iPhone app that could be used, and if the results of the pilot study prove successful they'll plan for a 12-month study.

Re-Envisioning Meal Dosing

Of course, this new idea of an FII has its critics -- including those who tend to agree that carb counting isn't best used as a stand-alone option. Dr. Howard Wolpert of Joslin Diabetes Center believes that both the FII and carb counting have their faults by themselves, and can only be considered as part of a larger picture. He's also been looking into the effectiveness of carb counting and possible alternatives, and suggests that "alternative insulin dosing algorithms for higher-fat meals" are needed.

He presented at our DiabetesMine D-Data ExChange event a few weeks ago, and the description of his short talk stated: "The shortcomings of this approach — which assumes that carbohydrate is the only dietary macronutrient that needs to be considered in mealtime insulin dose calculation — are further highlighted by our recently completed closed-loop research studies indicating that higher-fat meals require considerably more insulin coverage than lower-fat meals with identical carbohydrate content."

"It's hugely challenging and most people don't get it right," Wolpert said about carb counting. "Most people learn experientially what they need."

Wolpert thinks a hybrid of the old exchange system and the current carb counting system is a way forward, possibly with the FII mixed in. He sees limits on the index because it's only designed to look at the first 120 minutes past a meal, and many high-fat or protein-heavy meals last longer stay in the body longer than that.

"Anyone living with diabetes knows that food doesn't just say in the system for such a short period," he said.

Under Construction

This whole topic brings up images from my own past, when I was forced to use those rigid ADA exchange plans that limited what I could eat. That was back when I was growing up in the 80s and 90s, when looking at proteins and fats was part of my complicated meal-planning routine. Honestly, I was hugely relieved when I eventually went on an insulin pump and started using carb counting to achieve more flexibility in my diet. (I still do factor in non-carbs for setting extended boluses, as about 50% of protein grams and about 10% of fat grams turn into carbs over several hours.)

Thankfully, no one seems to be suggesting going all restrictive again, and whatever new approach may replace carb counting is still being worked out. But it's fascinating to see that this now-established method is being second-guessed.

"I don't favor going back to the old days when it was too restrictive, because controlling your diabetes meant losing motivation and people gave up," Wolpert says. "But we were so limited by insulins of those days, and tech that wasn't as mainstream as it is now. We have a better way to do this now, and a more structured or hybrid approach is needed for diabetes education."

The idea of this new FII index is intriguing, but it doesn't seem very practical, IMHO. Yes, fat and protein amounts are also listed on food labels, but it seems like the "algorithm" to cross-reference those with the carb amounts is going to require more D-math than most of us can handle... We're talking about revamping an entire way of life for PWDs here, and something that big is never easy.

A penny for your thoughts, Fellow PWDs!

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community.
The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines.
For more information about Healthline's partnership with Diabetes Mine, please click here.

Close

Add a comment ()

Archived Comments

Mary Dexter|2013-12-05

The FDA requires that the nutritional information listed on the package be at least 80% of the total, but has no guidelines for how much it can go over that number. Therefore, the grams of carbohydrate listed on a package may be that number, 80% below, or any amount higher. We can algebraically calculate the exact number of carbohydrates per serving and divide by our current insulin:carb ratio, but if the number we start with is wrong, our result will be way off. Also, because most of the public associates carb-counting with fad diets rather than blood sugar control, businesses are likely to underestimate the amount of carbs so that people will believe they can eat their product.Is it any wonder we often guess wrong?

June S.|2013-12-05

I am happy for the years I spent using the ADA Food Exchange Lists. I learned to eat a balanced diet, while many PWDs I meet who were diagnosed after carb. counting came into fashion think only about carbohydrates, and not about good nutrition. I do carb. count now, since I'm pumping insulin, but find that on work days I eat exactly the same breakfast and lunch, without any variation, since I know exactly how much insulin it will take to cover those foods and not go high or low while at work. In terms of those meals, it is boring and monotonous, but I enjoy the predictability of blood glucose levels that I get by not varying those meals at all.

Gretchen|2013-12-05

The FII sounds a lot like the "substance glycemic index" (SGI) that diabetic engineer Derek Paice came up with some years ago. He measured his BG excursions with a variety of foods, carby and noncarby, and assigned them a number in relation to 60 g of whole-wheat bread (not the best control as whole-wheat bread varies a lot in composition, but it's a start).You can see his results at www.dapaice.com. Click on "Diabetes and Diet." He has a list of his personal SGIs.Because Derek is a patient and not an academic, no one paid much attention to his idea. And of course YMMV. But I suspect it's like the glycemic index: different absolute numbers but relatively the same.Also, Derek is supposed to be type 2, but he controls with about 8 U of insulin a day, so he may be some other type.Even if you're not interested in SGI, his booklet, which is free for download, has lots of interesting experiments that are graphed. One, response to an apple, included both type 2 and type1. That's in the second booklet, "Effects of Aging."

Melissa K|2013-12-05

I always bolus for protein and fat. For me, 10% of fat and 35% of protein turn into carbs. I put those carbs in an extended bolus for 3.5 to 5 hours depending on how much fat is in the meal. Lowered my A1C from high 6s to 5.7 (the 5.7 was only one month on the program) so I am excited to see what my next A1C will bring. Rarely do I see a blood sugar over 140.

David|2013-12-05

My method is carb-counting plus crib notes for high fat/high protein meals. I dunno if any system can work universally for all PWD because the effect of fat/protein varies in amount and timing from person to person. For me, Chinese food is a 6-8 hour fat bomb. By trial and error, I figured out my fav cheese enchilada platter requires a whopping 15.4 units spread out over 4 boluses over 4.5 hours. My pump's bolus calculator would always require adjustment so I don't use it. There's a lot of potential in touch screen pumps to allow meal presets (with ability to deliver Combo/Extended) and a Note taking function.

susan f|2013-12-05

First off, damn Melissa, super jealous of your a1c!I think what scares me about a new scale is the combination of YMMV and autonomic neuropathy. I do NOT bolus any extra for fat and protein, and I eat a lot of it as a low carb-er, and that does seem to work for me. So clearly Melissa and I digest very very differently, so how can one scale work for us both? I do think that how fat and protein slow digestion does need to be addressed in training. For example, if I drink a glass of Bud's eggnog (OMG good), I don't need to bolus for a full HOUR after I take it. If the newly diagnosed aren't being given examples like that, that is downright dangerous.Oddly, I have very slow digestion due to gastroparesis, yet have yet to need a square or dual wave bolus (the eggnog is the first thing I've encountered where I need to change my bolus behavior in 30+ years of diabetes). One scale will not fit us all here due to the variability in each individual patient's digestion. With pure simple carbs, the scale fits more patients accurately than I think a new scale incorporating this data would.

Gretchen|2013-12-05

Oops. I indicated wrong link. The apple results are in Potpourri 1.

Lloyd M|2013-12-05

I count carbohydrates, and limit my carbohydrates to 80 a day. If I eat no carbohydrates at all for breakfast, then I need to bolus a bit for protein.My A1c has been in the low 5's every time for more than 6 years, with a standard deviation of 14 to 17. I'm Type II for 20 years, pumping for 7.For me, carbohydrate counting works very well.-Lloyd

Ange J.|2013-12-11

My aunt who's diabetic does the same thing. Initially she'd calculate her intake based on how much carbs the food has based on the package and at times her insulin levels would peak. I showed her this post to help her understand more about the efficiency of what she does.

Related posts

North Carolina D-Mom Pamela Heyward likes to describe herself as a "mom on a mission."That mission: To create a fast-acting glucose product that raises blood sugar quickly but isn't a glucose tablet and doesn't require all the guesswork that goes ...

Hypoglycemia isn't a laughing matter for those of us with diabetes, but a new awareness campaign is trying to put the "Ha!" into low blood sugar recognition and treatment.Ha!, as in the new org named Hypoglycemia Awareness.The five-month-old nonpr...

You might say that I take my coffee pretty seriously. Don't even think about asking me to do anything productive before I've had at least one cup in the morning, and you'd be quite mistaken to think that's the only one I'll be enjoying as the da...

Got diabetes questions? You came to the right place! Ask D'Mine is our weekly advice column, hosted by veteran type 1, diabetes author and educator Wil Dubois.This week, Wil gets a direct ask on how he feels about a controversial but well-known v...

It's no secret that I don't have the best teeth. My dentist has told me some of that is due to diabetes. And the rest: just plain ole disdain of tooth brushes and dental floss since I was a kid. My bad.Of course, this means that treating low blood...

Send us your feedback

We are unable to respond directly to questions, but your feedback is greatly appreciated, and will be taken into account in our ongoing review of our Health Reference Library.

Your Name:✖Please enter your name

Your Email:✖Please enter your email

Send me a copy

0

Email addresses will not be shared with 3rd parties. See privacy policy

Thank you.

Your message has been sent.

We're sorry, an error occurred.

We are unable to collect your feedback at this time. However, your feedback is important to us. Please try again later.

Close

Advertisement

Advertisement

Advertisement

Advertisement

Advertisement

Advertisement

Advertisement

Close

Advertisement

Healthline’s mission is to make the people of the world healthier through the power of information. We do this by creating quality health information that is authoritative, approachable, and actionable.

Join more than 30 million monthly visitors like you and let Healthline be your guide to better health.